A care home where vulnerable patients were subjected to horrifying ‘institutional abuse’ put shareholder profit ahead of the ‘humane delivery of treatment’, a devastating report found yesterday.

An independent inquiry into the Winterbourne View scandal also revealed that residents of the home attended accident and emergency departments 76 times in three years – yet no medics alerted the authorities.

The report lambasted the local NHS, police, and health watchdogs for not acting on dozens of complaints by patients and their families dating back up to five years.

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Inquiry: Panorama filmed residents at Winterbourne View being assaulted
and bullied. This poor woman was dragged across the floor in this undercover footage obtained by a whistleblower

Disgusting: Staff played games with the patients, shown here placing one
person under furniture with the other sat in the seat above. Campaigners have warned that another scandal like this could happen again

But some of the most scathing
criticism was reserved for Castlebeck Ltd, the firm which owned the home
– and was paid £3,500 a week by the NHS for every mentally ill patient
placed in the home, which is technically classed as a secure hospital.

The report, by independent expert Dr
Margaret Flynn, said the company ‘appears to have made decisions about
profitability, including shareholder returns, over and above decisions
about the effective and humane delivery of assessment, treatment and
rehabilitation’.

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It said Castlebeck – which is owned
by a Swiss private equity group – ‘took the financial rewards without
any apparent accountability’.

Dr Flynn said: ‘Unwittingly, the hospital has become a case study in institutional abuse.’

The report was commissioned after
Winterbourne View, which was on a business park outside Bristol, was
exposed by BBC1’s Panorama last year.

An undercover reporter recorded secret footage of patients being abused by carers.

The video appeared to show sickening scenes of vulnerable residents being pinned down, slapped, doused in water and taunted.

Since the broadcast, Castlebeck has
closed Winterbourne View, at Winterbourne in South Gloucestershire, and
two other of its string of residential homes in the UK.

On Monday, Michael Ezenagu, 29,
became the 11th ex-member of the home’s staff to admit offences relating
to the ill-treatment of patients.

They will be sentenced at Bristol
Crown Court at a later date.

Yesterday’s report laid bare the catalogue
of failings which allowed the abuse to go unchecked for years.

Between January 2008 and May 2011,
residents at Winterbourne View were taken to hospital 76 times –
including to be treated for epileptic seizures, injury, self-harm,
lacerations, removal of a foreign body and for a fall.

Horrific: This member of staff stamps on the patients hand in yet another shocking image from the now-closed home. The private hospital should have been a safe place for patients to be treated with compassion and care

But the report said: ‘Putting to one
side emotional, verbal and psychological harm… there was considerable
visible, physical and quantifiable violence at Winterbourne View for
which patients required hospital treatment and yet there were no
safeguarding alerts from accident and emergency.’

Brave: The abuse at Winterbourne was uncovered after this whistleblower spoke out

Meanwhile, South Gloucestershire
Council received 27 allegations of abuse by staff to patients at the
hospital, ten allegations of patient-on-patient assaults and three
family-related alerts.

Avon and Somerset Police recorded 29
incidents – including nine carer-on-patient incidents. These included
staff head-butting and punching patients.

Castlebeck itself recorded a total of
379 physical interventions – such as restraint – during 2010 and 129
for the first three months of 2011.

Yet it was only after the Panorama investigation that the authorities woke up to the true scale of the abuse.

Complaints had either been viewed in
isolation, or the authorities had sided with the accounts given by staff
rather than patients.

Dr Flynn said the ‘silencing’ of complaints by the victims was ‘scandalous’.

Peter Murphy, chairman of the South
Gloucestershire Safeguarding Adults Board, expressed the ‘deep regret’
of the organisations that make up the board for what happened at the
home.

A Castlebeck spokesman said: ‘We
believe we have responded [to the criticisms in the report] in a way
that demonstrates our resolve to ensure that the events of Winterbourne
View will not be repeated.’

Failure: The local primary care trust said many of the systems that could have stopped the shocking abuse of patients at Winterbourne View hospital failed but insisted standards had now improved